Table 8. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Universal Protocol
UP.01.01.01: Conduct a pre-procedure verification process Ensure that all relevant documents and information or equipment are: -Available before starting procedure -Correctly identified, labeled, and matched to patient’s identifiers -Reviewed and are consistent with patient’s expectations and team’s understanding of intended patient, procedure and site UP.01.02.01: Mark the procedure site -Mark at or near procedure or incision site -Preferably include proceduralist’s initials, with or without a line representing the proposed Incision -Use permanent marker that remains visible after completion of skin prep and sterile draping -Position marking to be visible after skin prep, patient positioning and sterile draping are completed UP.01.03.01: Perform a time-out immediately prior to starting procedures -Addressing correct patient identity, correct side and site, accurate procedure consent form and procedure, correct patient position, relevant images and results are properly labeled and appropriately displayed, safety precautions based on patient history or medication use, need to administer antibiotics or fluids for irrigation purposes |
Adapted from Joint Commission on the Accreditation of Healthcare Organizations [93,94].